Healthcare Provider Details

I. General information

NPI: 1851659353
Provider Name (Legal Business Name): RENJITHKUMAR KALIKKOT THEKKEVEEDU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5262
  • Fax:
Mailing address:
  • Phone: 601-984-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01089483A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number24321
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: